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Inquests

In most cases, a GP or hospital doctor can issue a medical certificate stating the cause of death and the registrar will then issue a death certificate. If death was unexpected or suspicious or if doctors are uncertain about the actual cause, the coroner is likely to be involved and an inquest may be held. 

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We know that an inquest won't bring back your loved one, but it can help give you the answers you've been desperate for. It can also help ensure that another family won't have to endure what you have been through.

The coroner's findings will help bring about a positive change, and will create a lasting legacy for your family, and you will know that the death was not in vain.

What is the purpose of an inquest?

The purpose of an inquest is to understand how someone died. By looking at who died and where and when, the inquest can ascertain the facts. The question of how they died is an important one, particularly for any fatal accident claims.

To succeed with a fatal accident claim, it is necessary to prove that the death was caused or contributed to by the negligent acts of others and a medical negligence claim or a personal injury claim can be brought.

Part of an inquest finds out what actions have been taken following an incident and what lessons can be learned following a death. This happened during the inquest of PC Richard Phillips-Schofield following a fatal cycle accident. Read about how this tragedy affected a positive change in British Cycling.

How can Shoosmiths help?

The death of a loved one can not only impact you emotionally but financially too, especially if the death was unexpected or suspicious. If you're undertaking a claim in which a coroner inquest is required, we can help.

Our team of experienced coroner inquest lawyers have handled many cases that have required an inquest and are among the most respected and experienced in the UK.

We'll be by your side throughout the inquest and can help give you informed and objective advice to guide you through the process and explain what's happening, as well as asking the right questions to ensure the coroner is able to reach the right verdict and ensure that this tragedy won't happen again.

If you'd like to know more about how Shoosmiths can help, contact us today. You can call 0808 231 1564 or send us a message to arrange a free phone call.

  • When is an inquest required?

    By law, the coroner must open an inquest into a death if there is a reasonable cause to suspect that the death was due to anything other than natural causes. There is no exact legal definition of a 'natural' cause of death. However, a common description is 'death due to a disease running its full course with no other intervening factors.' Advanced old age and extreme prematurity also count as natural causes. All other causes of death are regarded as non-natural.

    An inquest is therefore required when the death of the deceased occurred in the following situations:

    • The cause of death found at a post-mortem examination is non-natural
    • For inquests opened without a post-mortem examination, the cause of death given by the reporting doctor is non-natural
    • The cause of death is unascertained (not found) at post-mortem
    • There is other information giving reasonable cause to suspect that the death was non-natural
    • The deceased was in the care or custody of the state at the time of their death
  • What is the role of a coroner?

    The Coroner's job is to gather information to determine if a medical certificate of cause of death can be issued or if further investigations are required. If the certificate can't be issued, the coroner will order a post-mortem examination.

    The coroner as part of their investigation may instruct a pathologist to carry out a post-mortem examination (autopsy).

    The coroner is an independent judicial officer whose role is to investigate any death in their jurisdiction reported to them which is violent, unnatural, the cause is unknown or which occurs in prison, police custody or other state detention. For example, a patient detained under section 2 of the Mental Health Act.

    Since 2013, newly appointed coroners must have five years of legal practice or part-time judicial practice. Coroners who were in post before 2013 could be lawyers or doctors.

    It is important to remember that the coroner cannot apportion blame. The coroner does not decide or appear to decide any question of criminal or civil liability. It is an inquisitorial process involving an investigation followed by a hearing where evidence will be given under oath. The deceased's family has the right to participate in the proceedings and to ask questions of the witnesses, which is where the expertise of inquest solicitors is invaluable.

    If death occurred in hospital or a nursing home, the inquest may be the only time that doctors, nurses or carers will ever fully explain what they did and describe exactly what happened.

    This happened during the inquest into the death of Stephen Bridgman following brain surgery. Read about the inquest and discover how Shoosmiths was able to support the family.

  • Who refers a death to the coroner?

    The coroner receives notifications from a number of sources, including doctors, the police, medical referees and the registrar of births, deaths and marriages.

Start your journey today

Shoosmiths' team of dedicated coronial inquest lawyers will be with you every step of the way, doing everything in our power to ensure the inquest provides you with the answers you've been searching for and to help put procedures in place so that other families do not have to endure what you've been through.

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Phil Barnes

Phil Barnes

Partner

Medical negligence

Phil is national head of medical negligence. It has been said of Phil that he's the kind of guy to pull out all the stops so call Phil today.

Denise Stephens

Denise Stephens

Partner

Medical negligence

Denise is a passionate, highly skilled medical negligence lawyer with a heart of gold. She cares genuinely about getting you justice so tell Denise your story.

Kashmir Uppal

Kashmir Uppal

Partner

Medical negligence

Award winning medical negligence lawyer Kashmir is tireless in her pursuit of accountability. Contact Kashmir today.

Frequently Asked Questions

  • What happens before an inquest?

    If a coroner opens an investigation into an individual's death, they will liaise with that person's family (or inquest solicitors), the healthcare professionals involved and potentially the police. A post-mortem report will be prepared following an autopsy which may help the coroner established a cause of death.

    The coroner will usually invite written submissions from the family, which are typically prepared by specialist coronial inquest lawyers, on the key issues they should address at the inquest. This will often include whether they need to obtain any independent expert medical evidence to help determine how the death occurred, and crucially, whether the Human Rights Act obligations under Article 2 are engaged.

    Following written submissions, a pre-inquest review is often heard before the coroner at the coroner's court. This review will address any outstanding issues and the family of the deceased and the defendant are given the opportunity to submit their verbal view on the issues. These issues can include:

    • Who should be called to give witness evidence
    • Whether independent expert evidence is required to help the coroner reach conclusions about how the deceased died and, if so, the disciplines.
    • Whether a jury is required for the inquest
    • The length of the inquest
    • Whether Article 2 of the Human Rights Act is engaged
  • What is an Article 2 inquest?

    Article 2 refers to The European Convention on Human Rights, incorporated into law by the Human Rights Act (1998). Article 2 of the Human Rights Act is the right to life. It imposes positive obligations on the state to protect its citizens' rights, including the fundamental right to life.

    An Article 2 inquest allows the coroner to investigate someone's death in more detail than a 'normal' inquest. The line of questioning is to determine not only how the deceased died, but also in what circumstances.

    Article 2 inquests are engaged when the state or its bodies or organisations, such as hospitals, are involved in an individual's death. The coroner must agree that there was a failure to adequately protect against the risk of death, where it was known or ought to be known that there was a real and immediate risk of death.

  • What happens at an inquest?

    The family of the deceased and other interested parties will be invited to attend the coroner's court, which looks like a typical court room. A date for the inquest will be arranged when a coroner's investigation is complete. Where possible, the inquest will be held within six months of the death being reported. Because inquests are open, members of the public and press may be present too.

    To begin proceedings the coroner will explain how the inquest will be conducted. They will then determine who is present and if there is any legal representation. Evidence will then be given:

    • On oath by witnesses in person
    • By statements being read into evidence by the coroner
    • From reports, plans or other documents with which the coroner has been provided

    The coroner will ask if you have any questions for an individual witness or about the content of any statement or document which is read out. We can help ask the right questions to ensure that the coroner has all the facts and information needed to reach their verdict and that you are able to find out why your loved one lost their life.

    The coroner will then consider all the evidence and reach their conclusions. They will then record the details required by the Registration Act, which will allow them to register the death on behalf of the family.

  • Who are the witnesses?

    Coroners decide who should take part to give evidence as witnesses at an inquest. This will be different for each case, but may include doctors, nurses, police officers, eyewitnesses and any other relevant people.

    Not everyone who has written a report or made a statement will be present. The coroner can decide that some pieces of written evidence are brief or straightforward enough to be admitted on their own, without the author attending to give oral evidence. If a witness received a summons, they must attend the inquest.

    Witnesses will first be questioned by a coroner, and there may be further questions by ‘properly interested people’ or their legal representatives.  This can include:

    • Relatives of the deceased
    • The executor(s) of the deceased’s will, or person appointed as the deceased’s personal representative
    • Solicitors acting for the next of kin
    • Insurers with a relevant interest
    • Anyone who may, in some way, be responsible for the death
    • Others at some special risk or appearing to a coroner to have a proper interest
  • Do you need representation at an inquest?

    It's not legally necessary to have an inquest solicitor to represent you, because it's an inquest and not a trial. But having legal representation at an inquest means there is someone who can sit beside you. They can help guide you through the process, explain what is happening and raise any questions you have for the witnesses. If you are considering a possible coroner inquest compensation claim, having legal representation at the inquest is extremely valuable.

    Although the inquest will not address the issue of who was to blame for the death, your lawyer can ask questions and obtain information which could be helpful to your claim.

    Having a legal professional alongside you can also help with challenging procedural decisions made by a coroner. They can assist if you wish to overturn a conclusion and obtain a fresh inquest hearing because of an inadequate inquiry by the coroner.

    We can give you clear, uncomplicated options for a lawyer to represent you and your family's interests at an inquest, guiding you through the procedure and reassuring you that the right questions are being asked.

  • How long will an inquest take?

    Whatever the circumstances surrounding a death, the inquest is an early (and often the only) opportunity for relatives to hear what happened. How long it may take to get those answers has been difficult to predict.

    The coronial service is under tremendous pressure and bereaved relatives in some parts of the country have had to wait years for an inquest to even begin.

    Rules for coroners throughout England and Wales have been in place since 25 July 2013. Now the Chief Coroner for England and Wales oversees coroner services to ensure adherence to the new national code of standards. This is designed to lead to a more efficient system of investigations and inquests.

    Coroners must complete inquests within six months of being informed of a death or 'as soon as is reasonably practicable after that date'. This may take some time to implement as some parts of the country have longer waits than others. Any inquests that are not concluded within a year must be reported to the Chief Coroner with reasons for the delay.

    The purpose of an inquest is not to determine blame. It is to address the four questions of who died, where and when they died and how they came by their death. The conclusion, (previously called the verdict) will not identify someone as having criminal or civil liability.

    If there is criminal investigation into the death, the inquest will be adjourned pending the outcome of that investigation. If that investigation establishes the cause of death, there will be no requirement for the inquest to be resumed.

  • How has COVID-19 impacted coroner inquest claims?

    As a result of the pandemic, many inquests have been adjourned. This has meant that many families will have to wait longer for answers.

    If COVID-19 is mentioned on the death certificate, even if the virus did not cause the death, there will be no coronial investigation. This is because COVID-19 has been classed as a naturally occurring disease.

    However, as a body of legal professionals, we feel it is our duty to ensure that all unexpected deaths should be investigated. Our dogged determination can be seen in the inquest of Jesse Rollason, which found that the care Mr Rollason received fell below a reasonable standard.

    Here at Shoosmiths, we're passionate about affecting change. One of the many causes we're working on is to rectify the current law surrounding stillbirths. Alongside the Campaign for Safer Births we're campaigning for a law change to allow inquests for stillbirth cases. However, as a result of COVID-19, this law change has been delayed.

    If you or a loved one has been affected by the care given throughout the pandemic and someone has lost their life as a result of that neglect, we feel it is our duty to ensure that justice is served.

    Please contact us and we can listen to your experience and talk through next steps.

  • What are the potential conclusions?

    At the conclusion of the evidence the coroner will sum up the facts. If there is a jury, the coroner will direct them regarding the law. Conclusions of 'unlawfully killed' or 'suicide' must be proven 'beyond all reasonable doubt'. All other conclusions are dealt with under 'the balance of probabilities' and these can include:

    • Died from natural causes
    • Died from industrial disease
    • Died from want of attention at birth
    • Died from dependence on drugs/non-dependent abuse of drugs
    • Killed self – whilst the balance of mind was disturbed
    • Died as a result of an attempted/self-induced abortion
    • Died as a result of accident/misadventure
    • Killed lawfully
    • Killed unlawfully – murder, manslaughter, infanticide
    • Stillborn

    Neglect in the coroner's court does not imply negligence; however, the Coroner can add a rider of 'neglect' to the conclusion where they feel that there were missed opportunities or gross failures to provide medical attention.

  • Why bring a claim following an inquest?

    While the inquest may provide you with the answers to some of the questions you had about the circumstances of the death, it doesn't have many of the other elements that are important to a grieving family.

    Bringing a claim isn't just about receiving compensation, it can also help with closure. Obtaining an admission of liability or an apology is often what grieving loved ones are looking for.

    We know that money isn't your main priority when a loved one has died, but many families are hugely relieved when they are able to receive some financial compensation to help alleviate the additional financial pressure they may be facing following the death.

    If you need further advice about bringing a fatal claim, you can contact us today by calling 0808 231 1564 or send us a message to arrange a free phone call.

  • If the conclusion doesn't identify any failings, can a claim still be brought?

    While an inquest conclusion does help identify failings that can strengthen a claim, it doesn't necessarily provide the whole picture, particularly in negligence claims.

    Because the process of an inquest and fatal claim are different, it is possible for a claim to be brought even if the coroner didn't identify any failings. For example, during an inquest, the coroner may only look at the period of time immediately before their death, and not look at the treatment or care received over a longer period. All of which are important in establishing a fatal claim case.

    It's worth noting that the majority of fatal claims are brought where there is no inquest hearing at all.

  • Is it possible to challenge the conclusions?

    There is no right of appeal against the conclusion of a coroner's court, however, you can take it to the High Court to ask a judge to review the findings. This is a specialist procedure and seeking expert legal counsel is imperative as there is only a limited period of time to overturn the conclusion.

  • Can a funeral be held before the inquest has finished?

    In most cases, a funeral can be held. But delays can arise if someone is charged with an offence of causing death.

  • Can a death certificate be made available before the inquest has finished?

    The death cannot be registered until the coroner's investigation has been completed and the cause of death can be added to the death certification.  To enable the grieving family to arrange a funeral an interim death certificate can be issued which will simply confirm the identity of the person who has died and confirm the fact that they have died.  It will not provide further details of the death (such as cause of death) as these details will not be known until the inquest has concluded.

Find out more about the legal advice Shoosmiths can offer

Getting justice for a loved one takes real courage, knowing how complex and time-consuming coroner inquest claims can be. But by choosing Shoosmiths to represent you, we can take away that added burden.

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